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Mental Health Concerns as seen in the school setting Janice Selekman DNSc, RN, NCSN, FNASN Professor University of Delaware Why we are hesitant to engage in 1:1 counseling • • • • Lack of Time Lack of Space/privacy Perceived lack of expertise Unable to determine measures of success Health • • • • More than the absence of disease Mental health is crucial to our well being Mental health impacts on our relationships with others For children, mental health impacts on their ability to learn Mental Health - defined A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community (World Health Org. 2014) • Emotional well being (happy, peaceful, satisfied) • Psychological well being (accept self, optimistic, self directed, positive relationships, have purpose in life, in control) • Social well being (social acceptance, BELONGING, SENSE OF COMMUNITY, feel useful to society) CDC, 2013 Mental Health • “Establishment of mental health and emotional well being is a core task for the developing child” (AAP) • Social determinants of general health are the same as for mental health: adequate housing, safe neighborhoods, equitable jobs and wages, quality education, and equity in access to quality health care Mental Illness “Collectively all diagnosable mental disorders” or “health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.” (CDC) Diagnostic and Statistical Manual of Mental Disorders • American Psychiatric Association • The Bible of Psychiatry • The official guidebook???? Uses of DSM • Defines and standardizes the constellation of symptoms that are used to recognize and diagnose mental disorders – Determines who receives treatment – Assures some degree of reliability – Assures a common language • Determines who qualifies for special education • Who gets an IEP • Additional related services, including nursing • Special considerations regarding discipline • Who qualifies for a 504 Plan instead Mental Disorders • “A syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. • Usually associated with significant distress or disability in social, occupational, or other important activities. – An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual as described above.” (APA, 2013) • Having a Mental Disorder does NOT mean the person needs treatment • Having a Mental Disorder does NOT mean the person is ill or sick • Need for treatment depends on: – – – – – – How severe are the symptoms? Is there suicidal ideation? How much distress/ mental pain is the person in? Is there disability related to the symptoms? What are the risks and benefits of treatment? Is there comorbidity? Mental Wellness Continuum Mental Health-------------------------------------------Mental Distress 0 1 2 3 4 5 6 7 8 9 10 Prevalence: What are we seeing? • 21% of children and teens meet diagnostic criteria for a mental health disorder and have evidence of at least minimal impairment; approximately half of these children have significant functional impairment (AAP, 2010) – 1:5 • An additional 16% have a Mental Health Problem In the past 3 years, I have taught students with the following chronic conditions (N=1280) • • • • • • • • • • • • Attention Deficit Hyperactivity Disorder Asthma Learning Disabilities Allergy (other than food) Food allergy Autism Spectrum Disorder Anxiety Disorder Speech Impairments Depression Diabetes Vision Disability Bipolar Disorder 93.2% 88.5% 78.9% 76.2% 70.6% 65.2% 58.3% 56.5% 49.9% 48% 42.1% 41.4% • • • • • • • • • • • • Significant Obesity Deaf/hearing deficits Seizure disorders Obsessive-Compulsive disorder Intellectual Disability Heart conditions Sickle cell disease Skin disorders Addictions Color blindness Eating disorders Cancer 35.7% 34.5% 34.3% 28.7% 25.2% 22.7% 20.5% 20.2% 19.8% 17.5% 16.6% 15.2% Prevalence????? Ages 12-17 • Learning Disabilities • Mood disorders 5%-15% 10.7%-11.2% – 3F:1M (16.2%:5.3%); 56% white; 38% received treatment • • • • Behavioral disorders Anxiety Disorders ADHD Autism 9.6% 8.3% 7.2% 1.1% YRBS 2015 • Felt sad or hopeless every day for 2 or more weeks in a row so that they stopped doing some usual activities during the 12 months before the survey – US = 29.9% (40%F: 20%M) WEST VIRGINIA = 32.9% (43.8%F:22.4%M) • Percent who reported they seriously considered attempting suicide – US = 17.7% (23%F; 12%M) WEST VIRGINIA = 18.7% • Percent who reported they attempted suicide one or more times during past 12 months – US = 8.6% (11.6%F:5.5%M) WEST VIRGINIA = 9.9% • Made a suicide plan – US = 14.6% (19.4%F: 9.8%M) WEST VIRGINIA = 15.4% ATTEMPTED SUICIDE • US = 8.6% (11.6%F: 5.5%M) – 9th-12th grade – Highest in Hispanics and in 9th graders – For every suicide, there are 25 suicide attempts – WEST VIRGINIA = 9.9% (11.3% F: 5.5% M) • US suicide rate – Between ages 5 and 11: 017/100,000 • Suffocation and strangulation – Between ages 12 and 17: 5.18/100,000 • Firearms – 1/3 have mental health problems (60% with ADHD – more impulsive) Suicide among younger children • More often experienced relationship problems with family and friends (60%) compared to teens (46%) • Less often experienced boyfriend/girlfriend issues (0%) compared to teens (16%) • Did not leave a suicide note (7.7%) compared to teens (30%) • Had ADHD (59%) compared to teens (65.6%) • Were depressed (33.3%) compared to teens (65.6%) Who is getting treated? • 20%-36% of those with mental disorders are identified and receive mental health services – – – – – – 60% for ADHD 45% for CD and ODD 38% for mood disorders and bipolar 18% for anxiety disorders 15% for substance use disorder 13% for eating disorders • 40% have co-morbidity (includes over 50% of those with ADHD Ages when Mental Disorders start • • • • Anxiety disorders – age 6 Behavior disorders – age 11 Mood disorders – age 13 Substance use disorders – age 15 • Half of all lifetime cases of mental disorders begin by age 14 Consequences of Untreated Mental Disorders • SUICIDE – 3rd leading cause of death in 15-24 year olds; 90% had mental disorder • School absence • School failure – Half of those 14 and older with mental disorders drop out of school • Juvenile and criminal justice systems involved – 65% of boys and 75% of girls in juvenile detention have at least I mental disorder • Higher healthcare utilization Risk Factors • • • • • • • • • • • ALL TEENS Those who are GLBT Those with chronic conditions Those who are abused Drug and alcohol use Those with poor coping skills Learning problems/school failure LACK OF SCHOOL/COMMUNITY CONNECTEDNESS Rejection/bullying/jealousy/not loved/ break up School pressure to succeed Poor parenting (no rules, no respect, no love) Changes with DSM5 • Mental Retardation is now called Intellectual Disability – Must have low IQ score AND decreased ADAPTIVE FUNCTION • How well a person meets community standards of personal independence and social responsibility • Autism Spectrum Disorder – Deficits in social communication and social interaction – Restricted repetitive patterns of behavior, interests, and activities – Aspergers is no longer a recognized diagnosis • Learning disabilities – Impairment in reading, written expression, and mathematics Changes with DSM5 • ADHD – ADHD-Predominantly Hyperactive/impulsive presentation – ADHD – Predominantly inattentive presentation – ADHD – Combined presentation • There is no longer a condition called ADD • Disruptive Mood Dysregulation Disorder – For children >6 with bursts of anger and chronic irritability • Prementrual Dysphoric Disorder • Excoriation (skin picking) disorder • Binge Eating Disorder (once/week for 3 months) Changes with DSM5 • Gambling Disorder • No longer differentiate between substance abuse and dependence • MILD NEUROCOGNITIVE DISORDER – “Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual motor, or social cognition) based on – Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function” – The deficits do not interfere with capacity for independence in everyday activities, such as paying bills, managing medications, but greater effort may be required Conditions for further study • Caffeine Use Disorder • Internet gaming disorder • NONSUICIDAL SELF-INJURY – 5 or more days in past year – Damage to surface of body to induce bleeding, bruising, or pain injury with no suicidal intent – Engaged in injury to 1) obtain relief from negative feeling, 2) resolve an interpersonal difficulty, or 3) induce a positive feeling state. Self Injury • Deliberate infliction of a wound to oneself in an attempt to seek expression of and immediate relief from intolerable feelings. Mental Health Screening • ONLY IF APPROPRIATE SYSTEMS ARE IN PLACE TO ENSURE ACCURATE DIAGNOSIS, TREATMENT, AND FOLLOW-UP – (AHRQ, 2009) Treatment Barriers • Inaccessible • Shortage of providers, especially for low income and for rural areas • Shortage of parenting programs • Shortage of school-based mental health programs and services • Shortage or lack of awareness of emergency mental health services for children and adolescents in crisis We can screen for Mental Health • Pediatric Symptom Checklist – psychosocial screen to facilitate recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated. – Parent and youth versions (for ages 11+) – Parent version cutoff is 28 or higher – Youth version is 30 or higher indicates psychological impairment • Patient Health Questionnaire (depression) – Do you have interest or pleasure in doing things? – Have you been feeling down, depressed, or hopeless during the past 2 weeks? Suicide Questions • Have you thought about ending your life or harming yourself • Do you have a plan • Do you have access to the means to carry out plan • Do NOT leave them alone • Have a pre-determined plan with principal or counselor or EMT or community service Concussion • Enhances neurologic symptoms present for any existing mental disorder • Makes it harder to differentiate concussion symptoms and the symptoms of the mental disorder Bullying: WHAT NOT TO SAY • • • • • • • “JUST IGNORE THEM” “STAND UP AND FIGHT” “KIDS WILL BE KIDS” “KIDS SURE CAN BE CRUEL” IT’S JUST A SMALL MINORITY YOU MUST HAVE DONE SOMETHING TO DESERVE IT THIS WILL PREPARE YOU FOR THE REAL WORLD Bullying: WHAT NOT TO DO • NOTHING • ASSUME THAT IT IS HARMLESS • DON’T DISCOUNT OR MINIMIZE Bullying: INTERVENTIONS • TALK TO YOUR KIDS – What causes people to bully each other? – How does it feel to be bullied? To bully? – What are the effects of bullying on the victims, the bully, and the bystanders? • WHAT WOULD THE SCHOOL AND SOCIETY BE LIKE IF BULLYING BEHAVIOR WAS ACCEPTABLE • Why do people not like or fear people who are different? – USE EXAMPLES FROM HISTORY, POLITICS, AND CIVICS (concentration camps) – TIE IN PREJUDICE INFORMATION (slavery) • What can we do to stop it? • What are the dilemmas we face in trying to stop bullying? Bullying strategies Reductions in bullying were associated with: • Parent training • Increased playground supervision • Non-punitive disciplinary methods • Home-school communication • Effective classroom rules • Effective classroom management • Embed discussions in curriculum • Social-emotional learning approaches • No tolerance vs. no bully policies Interventions for cyber-bullying • Do not respond to the online threat or comment. • Save the evidence; do not delete it. • Report it to the website, and/or the internet service provider • Involve school administration to determine a plan of action, relating to cyber-bullying in the school’s bullying policy. Electronic Aggression: Parent Tips • Talk to your child – Ask where they are going and who they are going with – For youth, going “online” is like going to the mall; ask the same types of questions you would if they were going there • Develop rules – Develop rules about acceptable and safe behaviors for all electronic media focusing on ways to maximize the benefits of technology and decrease its risks • Explore the Internet – Visit the websites your child frequents, and assess the pros and cons • Talk with other parents and caregivers • Connect with the school • Educate yourself Policy Development • Differentiate bully behaviors from being a bully • Include everyone involved: administration, teachers, parents, students • Define it • Determine consequences • Advertise it MORE INTERVENTIONS • Promote trust – That you will be there for them and protect them – That you will do something. • Be aware that it occurs and BE THERE • Create an environment that will not tolerate bullying • Do not allow the excuse, “I was just teasing”! • • • • • • Be positive role models in managing relationships Emphasize sharing, helping, caring, RESPECT Teach the ‘Golden Rule’ Discuss “Am I my brother’s keeper” Teachers must act; Parents must support and act Tell kids ‘it is not tattling…it is protecting someone’ For The Target • • • • TEACHER CHOOSES TEAMS/ PARTNERS ASSURE THEY ARE NOT IN THE SAME CLASS AS BULLY EMPOWER THEM TO KEEP LOGS/ DIARIES STAY CALM AND MAKE MENTAL NOTES OF WHO SAID AND DID WHAT. • USE TRAINING AND REHEARSAL • PROMOTE POSITIVE SELF ESTEEM • INVOLVE WITH PEERS FOR THE BULLY AND VICTIM • STAY CALM • HAVE A CLEAR DIRECT MESSAGE TO AVOID INTERACTIONS • MAKE A SIMPLE STATEMENT OF WHAT YOU DO OR DO NOT WANT TO HAPPEN • ESTABLISH GROUND RULES SO THEY CAN CO-EXIST TOGETHER FOR THE BYSTANDER • EXPLAIN THEIR ROLE IN PROMOTING THE BULLYING • EXPLAIN THEIR ROLE IN STOPPING IT (DEFENDER/ BEFRIENDER) • TEACH THEM TO DISTRACT BULLY SO VICTIM CAN WALK AWAY • DO NOT PROVIDE AN AUDIENCE Cutting: How to respond Do NOT respond with shock or horror ◦ Be nonjudgmental ◦ Have a low key approach Do NOT demand that the self-injurious behavior stop Do NOT push the teen into a defensive mode “This really tells me how badly you are hurting” “I’m glad you’ve told me and I’m committed to helping you get through it in your own way” SAFETY FIRST Assessing scars Depression • If you had 3 wishes… • If something magical happened over night and tomorrow when you woke up ONE thing could be different, what would it be. • Praise them • Recognize them • INVOLVE THEM If they are placed on psychotropics • Black Box Warnings – The strongest warnings the FDA requires and indicate that the drug carries significant risk of serious or even life-threatening adverse effects. – The black box warnings are attached to many antidepressants, especially SSRIs – Usually read that the drug will increase the risk of suicidal thoughts and behaviors in children and adolescents up to age 25. – While the benefits outweigh the risks related to the treatment of depression and anxiety disorders, it is a side effect requiring vigilant assessment. Interventions • Supportive counseling – active listening, – expressing empathy, – validating and normalizing the person’s experience, • Problem solving process (let’s brainstorm) – – – – Analyze problem Identify pros and cons Select one solution Support child in implementing Interventions • Basic cognitive interventions • Teach – Every interaction is an opportunity to teach. We all do teaching – You need to teach them to manage emotions and cope. – There is a difference between giving advice and teaching them how to think • Do they need a 504 plan – A place to go for stress or bursts of anger – Identify the antecedents – Advocate • Support groups – Children of divorce, Gay-Straight Alliance, family support Roles/ Expectations of Parents/ Guardians • • • • • • Provide care (feed, shelter, clothe, maintain good health) Nurture, motivate, support, comfort, Protect – ensure safety Train/ educate Develop social skills Be primary decision-makers in the home Roles/ Expectations of Parents/ Guardians • • • • • • Be chief interpreters of the wider community and society Be ROLE MODELS Be a safety valve to reduce social pressures on the individual Provide stability Have rules LOVE unconditionally Help them feel connected • Magic Mondays Help them feel connected and accepted Magic Mondays You approach them; don’t wait for them to approach you